Learning from the best

Leslie Curry, PhD, has seen the best and the worst of U.S. hospitals. In an effort
to pinpoint the characteristics of top-performing hospitals, Dr. Curry and colleagues
visited 11 that ranked in either the top 5% or the bottom 5% in acute myocardial infarction
(AMI) mortality rates, according to the Centers for Medicare and Medicaid Services.
They interviewed 158 staff members, including administrators, nurses and hospitalists,
about their practices and procedures related to heart attack care.

The interviews revealed notable differences, but not in the protocols that are usually
targeted by improvement programs (such as use of rapid response teams or guidelines
or hospitalists). “Hospitals in the high-performing and low-performing groups
differed substantially in the domains of organizational values and goals, senior management
involvement, broad staff presence and expertise in AMI care, communication and coordination
among groups, and problem solving and learning,” the researchers concluded
in a paper in the March 15 Annals of Internal Medicine.

Leslie Curry, PhD.

ACP Hospitalist recently spoke with Dr. Curry, who is a research scientist and lecturer in public
health at Yale University, about what these findings mean for future improvement campaigns,
lower-performing hospitals, and individual hospitalists.

Q: How did the results compare to your expectations?

A: We did expect to see some protocols and practices, because there's a lot of effort
focused on figuring out how to improve AMI care and evidence that these things are
important. We heard a fair amount about protocols and practices [but] these didn't
distinguish between the high and low performers.

What was kind of a surprise was the intensity and degree to which people talked about
more relational aspects of work. One of the things that was striking to us was the
deliberate attention toward collaboration across the hierarchies. I can remember talking
to this interventional cardiologist at one of these exceptionally performing hospitals
who said very matter-of-factly that they look to the cath lab techs for solutions.
They are just incredibly respectful of diverse opinions and engagement of frontline
staff.

Q: Given what you found, what can the low-performing hospitals do to improve their performance?

A: It is more than practices and protocols. It's these aspects of diverse teams and collaboration
and non-punitive environments. Of course, these are things that are much harder for
people to imagine implementing; however, we report in the paper some individual and
group behaviors and we believe if they are adopted and sustained over time they can
influence the organizational environment. We've just finished the second phase of
the study, a survey of a nationally representative sample of U.S. hospitals. That
paper will report out practices and protocols and aspects of the environment that
are statistically significant in terms of predicting performance.

Q: Did finances affect a hospital's ability to be a high performer?

A: Evidence indicated financial resources are part of the picture, but this does not
explain the whole story. We couldn't assess that with this study because of the methodology,
but we did include high-performing hospitals in low SES [socioeconomic] settings and
low-performing hospitals in high SES settings. It is important to note that a lot
of what we heard about is not necessarily expensive. It wasn't the most advanced techniques
or equipment or technology that differentiated the hospitals. We might be able to
do some things that improve quality without adding a lot to cost.

Q: What about hospitalists? Did they play a role?

A: We were fortunate to have a hospitalist on the team because diversity of perspectives
is important. [See sidebar.] And we did hear about hospitalists, although this was
not an explicit focus of the study. But there were positive comments to the effect
that it was easier to get loose ends tied up because the hospitals had hospitalists.
In one low-performing hospital, there was an interview that talked about turbulence
in the hospitalist group, created in part by physician turnover when the hospital
wasn't able to bring in enough hospitalists or retain them for long enough periods
of time. It is my own sense the role of hospitalists has potential to be important,
in particular in communication and collaboration across groups.

Q: What else can be done to make the low-performing hospitals more like the high-performing
ones? Can individual physicians make a difference?

A: The physicians in the high-performing hospitals just had this incredible focus on
quality and really were very open—if they made a mistake, putting it forth
as a learning opportunity rather than blaming; this real sense of camaraderie to the
end goal, looking to other staff like nurses and pharmacists and hospitalists to learn
from.

Certainly there's a role for hospital leadership and management, and there may be
a role for financial resources, but we learned that it is also about individuals and
how they treat each other, the smooth information flow among groups, the willingness
to share information, the ability to look at adverse events as an opportunity to learn—valuing
innovation and creativity and trial and error.

Q: Could the differences you pinpointed be uncovered by physicians during a job interview?

A: On a job interview, I would try to pay attention to the climate—what it feels
like being there. Are there conversations happening in the hallways? When we did these
site visits, we saw really interesting public displays of data and of performance
metrics. There may be signals within an organization's environment that could give
somebody a sense of whether or not it's a place that really embraces this kind of
collaborative learning, coordination and communication.

A hospitalist perspective

Kate Goodrich, MD

The team that studied top- and low-performing hospitals not only interviewed hospitalists,
but also brought one of them along. Kate Goodrich, MD, now a medical officer with
the Department of Health and Human Services, told ACP Hospitalist about her experience as a researcher on the project.

What did you observe about the role of hospitalists?

I visited two of the high-performing hospitals where I performed qualitative interviews
with hospitalists. One of the common findings in these hospitals was the degree to
which the hospitalists were integrally incorporated into the quality improvement activities,
particularly those focused on the transitions of care.

One of the more impressive things I noted was the value that was placed on really
trying to improve the transition process through a variety of different mechanisms,
which included putting processes in place to ensure good communication with the outpatient
physicians. It was just an expectation in those hospitals that hospitalists would
communicate with the primary care docs throughout the hospital stay and that they
would have the discharge summaries completed and sent to the PCP prior to the patient
leaving the hospital. These hospitals had implemented all the processes that you would
like to be able to implement in your own environment, but are often difficult because
the proper systems are not in place. In the hospitals I visited, the right infrastructure
was in place and the hospitalists were very involved in developing and designing those
systems and ensuring their sustainability.

What can hospitalists do to make their hospitals more like the high-performing ones?

I think hospitalists should advocate strongly for resources that can facilitate improvement
within their environment. These won't always be monetary resources; the most important
resource for some hospitals may be nursing leadership support or having a pharmacist
make rounds with the provider team. In my personal clinical experience, it's hard
for any individual hospitalist or a hospitalist group to be able to implement system
improvements that work reliably and are sustainable, without having an infrastructure
and organizational culture that makes those changes possible.

From my observations, these two hospitals' cultures were ones in which the organizational
leadership sought the help of the physicians to improve patient care. The hospitalists
I spoke with had advocated for and participated in the design of the hospitals' care
transition processes, ensuring a design that aligned with their natural workflow.

What other lessons should hospitalists take from this?

If your organization leadership is not one that might automatically go to the hospitalists
to ask for their input or opinion on issues related to quality improvement or system
re-design, I would say that it's well within the purview of hospitalists to make sure
your views are represented. What can be frustrating is when the hospital implements
a new system for a particular process that directly affects physician workflow or
patient care and [hospitalists] haven't had input. Such systems will have greater
physician buy-in and may actually prove more successful and sustainable if hospitalists
are involved from the start and through the life of the project.

Another important area in which hospitalists can play an important role is in the
communication and coordination of patient care across groups. From my observations
on this study, the hospitalist culture in the high-performing hospitals was one of
team management of patients with a strong emphasis on frequent structured communication
with all staff involved in patient care.

This study really focused on AMI care. While we can't prove this, I imagine that our
findings related to the organizational elements that are associated with improved
mortality, and are likely to also be key for outcomes in other conditions. It just
kind of makes sense.

ACP Hospitalist provides news and information for hospitalists, covering the major issues in the field. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated.